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Understanding health through everyday social practices
- 1. Understanding health through social practices: performance and materiality in everyday life SCI Seminar Series, 1st September 2014 Dr Cecily Maller Centre for Urban Research Beyond Behaviour Change Research Group RMIT University, Melbourne cecily.maller@rmit.edu.au www.rmit.edu.au/research/urban/beyondbehaviour
- 2. Aim and introduction •Changing lifestyles to achieve better outcomes for health or sustainability is complex – efforts to date have mixed success •Health promotion—and behaviour change for sustainability—critiqued for: –supporting neoliberal agendas –treating structure and agency independently –placing responsibility on individuals Centre for Urban Research RMIT University © 2014 2
- 3. The Ottawa Charter for Health Promotion •Aimed to create ‘health for all’ by 2000 •Prerequisites of health: –peace –shelter –education –food –income –a stable eco-system –sustainable resources –social justice, equity Centre for Urban Research RMIT University © 2014 3 RMIT University © 2013
- 4. Background •Health promotion aims to create health through changing social, economic and environmental conditions (structural) •Strengthening the skills of individuals (behavioural) •Can overlook how health is created and experienced on an everyday basis … Centre for Urban Research RMIT University © 2014 4
- 5. “The health promotion movement has the possibility of re-inventing itself in the twenty-first century” If as Baum (2008, p. 464) says: My aim is to draw on theories of social practice to consider how health can be re-conceptualised and understood Centre for Urban Research RMIT University © 2014 5
- 6. Some guiding questions 1. What new ways of thinking about and understanding health might assist HP in achieving ‘health for all’? 2. How can we better address the socio-technical dimensions of how health is lived and experienced everyday? 3. What might new (socio-technical) directions for HP look like? Centre for Urban Research RMIT University © 2014 6
- 7. Theories of social practice •Sociological theories of social practice are at the cutting edge of sustainability and consumption research Centre for Urban Research RMIT University © 2014 7
- 8. The practice of eating breakfast What to eat for breakfast, when, with whom, where, why Skills how to source/shop for/ store/prepare/cook/eat/ share breakfast food Meanings Centre for Urban Research RMIT University © 2014 8 Materials Food/ingredients, condiments, shops, recipes, kitchens, appliances, utensils, crockery etc. (Maller in press adapted from Shove et al. 2012; )
- 9. Two key features of social practice theories… 1. They incorporate the role of technologies and things in daily life, focusing on socio-technical relations rather than the purely social Recognise the agency of materials, objects in construction of everyday life: the things that co-constitute practices (Schatzki 2010; Reckwitz 2002a) Centre for Urban Research RMIT University © 2014 9
- 10. 2. Practices are recognised as discrete entities with particular histories and future trajectories —Entities are distinguished from moments of observable performance (Performance) Spurling et al 2013 http://www.sprg.ac.uk/projects-fellowships/theoretical-development-and-integration/interventions-in-practice---sprg-report (accessed 11/10/13) Centre for Urban Research RMIT University © 2014 10
- 11. Using SPTs in empirical research —Selandra Rise ... a healthy and engaged community •Master planned estate designed to try and improve residents’ health and wellbeing Centre for Urban Research RMIT University © 2014 11
- 12. Centre for Urban Research RMIT University © 2014 12
- 13. BMI: High overweight and obesity rates More men are affected but women’s rates of overweight/ obesity are higher than City of Casey/Australian population Just over half sufficiently active Centre for Urban Research RMIT University © 2014 13
- 14. Few work close to Selandra Rise Centre for Urban Research RMIT University © 2014 14
- 15. Nearly 1/5 of residents eat take away food 3 to 10 - or more - times per week Centre for Urban Research RMIT University © 2014 15
- 16. On moving to Selandra Rise residents are finding it more difficult to get to and from shops to buy food If we don’t have milk we have to drive…we thought … we’d be able to sort of get everywhere without driving. Lucy Centre for Urban Research RMIT University © 2014 16
- 17. More Selandra Rise households own multiple cars than those yet to move to the estate Centre for Urban Research RMIT University © 2014 17
- 18. Selandra Rise residents are significantly less satisfied with…. Centre for Urban Research RMIT University © 2014 18
- 19. Practices do not exist in isolation: they are ‘materially interwoven’ with some practices… And are in competition with others “Travel time to and from work is the biggest challenge everyday.” Centre for Urban Research RMIT University © 2014 19 Survey participant
- 20. Moving from ‘behaviours’ to ‘practices’ •Applying social practice theory to research on health means health and wellbeing are outcomes of participating in a set of social practices –rather than the result of individual behaviours and/or external structural factors and context Centre for Urban Research RMIT University © 2014 20
- 21. •Healthy and unhealthy behaviours do not directly translate as social practices ‒e.g. smoking, drinking not necessarily practices in themselves ‒Instead they are part of practices, e.g. going out with friends, seeing a band Centre for Urban Research RMIT University © 2014 21
- 22. •Classifying practices as healthy/unhealthy: –Potentially excludes some practices that have health outcomes, e.g. driving, doing housework –Perpetuates unhelpful binaries of ‘good’ and ‘bad’ Every practice could be said to have health outcomes Centre for Urban Research RMIT University © 2014 22
- 23. New (socio-technical) directions for HP? •Reframe existing HP programs and policy to target social practices •Encourage new combinations of elements or replace existing ones –e.g. shift meanings, create new skills, recognise agency of materials •Recognise relationships between practices: competition, cooperation, symbiosis (Shove & Pantzar 2005) Centre for Urban Research RMIT University © 2014 23 RMIT University © 2013
- 24. •Some existing HP programs emanate a social practice approach –E.g. Stephanie Alexander kitchen garden program: practices of growing, harvesting, preparing, and sharing fresh food Source: http://www.kitchengardenfoundation.org.au/join-the-program/program-funders/queensland-program (accessed 22/11/13) Centre for Urban Research RMIT University © 2014 24
- 25. Conclusion •Social practices mesh well with HP: –Acknowledges both structure and agency –Looks beyond ‘health’ policy to all policy sectors –Works upstream Centre for Urban Research RMIT University © 2014 25
- 26. Conclusion •Social practices could help HP: –Move away from structure/agency binaries –Incorporate materialities/technologies in daily life –Delve further into complexity –Get closer to achieving the aims of the Ottawa Charter? –Connect with sustainability and consumption Acknowledgement: Funding for this research is generously provided by The Victorian Health Promotion Foundation through a Research Practice Fellowship, 2010-2015 Centre for Urban Research RMIT University © 2014 26
- 27. References Ayo, N 2011, 'Understanding health promotion in a neoliberal climate and the making of health conscious citizens', Critical Public Health, vol. 22, no. 1, pp. 99-105. Baum, F 2008, 'The Commission on the Social Determinants of Health: reinventing health promotion for the twenty-first century?', Critical Public Health, vol. 18, no. 4, pp. 457-466. Giddens, A 1984, The Constitution of Society: Outline of the Theory of Structuration, Polity Press, Cambridge. Lindsay, J 2010, 'Healthy living guidelines and the disconnect with everyday life', Critical Public Health, vol. 20, no. 4, Centre for Urban Research RMIT University © 2014 27 pp. 475-487. Maller, C. (in press). ‘Understanding health through social practices: performance and materiality in everyday life.’ Sociology of Health and Illness, (accepted 5th May to be published in Volume 37 (1) January 2015). Pantzar, M. and Shove, E. (2010) Temporal rhythms as outcomes of social practices. Enthnologia Europaea, 40(1), 19- 29. Petersen, A & Lupton, D 1996, The New Public Health - Health and Self in the Age of Risk, Sage Publications, St Leonards. Reckwitz, A 2002a, 'The Status of the "Material" in Theories of Culture: From "Social Structure" to "Artefacts"', Journal for the Theory of Social Behaviour, vol. 32, no. 2, pp. 195-217. Reckwitz, A 2002b, 'Toward a Theory of Social Practices: A Development in Culturalist Theorizing', European Journal of Social Theory, vol. 5, no. 2, pp. 243-263. Schatzki, T 2010, 'Materiality and Social Life', Nature and Culture, vol. 5, no. 2, pp. 123-149. Shove, E, Pantzar, M & Watson, M 2012, The dynamics of social practice: Everyday life and how it changes, SAGE, London, UK. Spurling, N, McMeekin, A, Shove, E & Welch, D 2013, A Practice Perspective for Sustainability Policy Interventions, Sustainable Practices Research Group, Manchester University United Kingdom, Manchester Strengers, Y & Maller, C 2011, 'Integrating health, housing and energy policies: the social practices of cooling', Building Research & Information, vol. 39, no. 2, pp. 154-168. Wilkinson, R & Marmot, M 2003, Social determinants of health: The solid facts, World Health Organisation, Copenhagen. World Health Organization, 2012 Summary Report: World Conference on Social Determinants of Health, Brazil 19021 October 2011, WHO Geneva Switzerland World Health Organization 1986, Ottawa charter for health promotion, World Health Organization, Health and Welfare Canada, Canadian Public Health Association, Ottawa. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/ (accessed 11/11/2013) RMIT University © 2013
Notes de l'éditeur
- Understanding health through social practices: performance and materiality in everyday lifeThe social context is recognised as playing an important role in understanding and improving health outcomes as evidenced by international recognition of the social determinants of health. However, although this recognition has guided the way health promotion is addressed globally, the aim of the Ottawa Charter to create health for all by the year 2000 has not been achieved. Further, in post-industrial societies it is now evident that existing health promotion approaches have not averted large scale health problems such as obesity. This presentation will delve into contemporary theories of social practice as used in consumption and sustainability research to provide an alternative, and more contextualised means, of understanding and explaining human action in relation to health and wellbeing. To progress incorporating social theory into health, researchers have used Giddens’ and Bourdieu’s conceptualisations of ‘social practice’ to understand relationships between agency, structure and health. However, social practice theory(ies) have more to offer than has currently been capitalised upon. The paper will reconsider how health can be understood and interpreted by drawing on theories of social practice as developed by Theodore Schatzki, Andreas Reckwitz and Elizabeth Shove among others. Two key observations are made. First, the latest formulations of social practice theory distinguish moments of practice performance from practices as persistent entities across time and space, allowing for empirical application and explanation of practice histories and future trajectories. Second, they emphasise the materiality of everyday life, foregrounding things, technologies and other non-humans which cannot be ignored in a technologically-dependent social world. By using practices as the entity of enquiry rather than the behaviours of individuals, and by exploring these and other aspects of health and wellbeing as socio-technical phenomena, the paper expands how health can be understood and highlights what future health promotion might entail for understanding and addressing current problems.
- Faced with complex problems such as obesity, climate change and over-consumption the majority of approaches for programs and policies turn to lifestyles or behavioural change as one, sometimes the only, form of intervention. Although there have been a few successes, efforts to date have generally been mixed, while the problems are more pressing than ever. In looking to understand why, health promotion as well as behaviour change for sustainability, have been criticised for supporting neoliberal agendas (Ayo 2012). Usually treating structure and agency or behaviour independently in the design of programs and interventions (Baum 2008) Emphasising and placing responsibility for change squarely on the shoulders of individuals As a brief intro to HP for those that are unfamiliar… Health promotion has been described as the: ‘process of enabling people to increase control over, and to improve, their health…Health promotion …puts health on the agenda of policy makers in all sectors and at all levels...’ (WHO, 1986) – in other words, not just the health sector. In essence, HP aims to work at a number of levels to improve the living, working conditions as well as change individual behaviour.
- By way of background, in 1986 the first conference on health promotion was held in Ottawa, Canada amid calls for a new public health movement. As a call to arms, the Ottawa charter was an agreement created and endorsed by delegates and included among other aims, the goal of creating health for all by the year 2000 through better health promotion. A number of actions were listed, as well as recognition of a number of prerequisites of health. In other words, there was formal recognition of the social and environmental conditions for health.
- There are largely two main approaches in health promotion – targeting policies and programs to create health through improving social, economic and environmental conditions And strengthening the skills of individuals, usually through behaviour change. This conceptualisation attempts to get at and solve health problems from opposite ends but at the same time it usually tackles structural and behavioural – or agentic - approaches independently. And the same binaries exist in sustainability research and policy. Perpetuating this binary/treating these strategies separately can overlook how structure and agency are entangled together in everyday life where health is created and experienced through daily routines.
- Obviously the Ottawa charter has not been achieved. However, rather than giving up, Baum has suggested “the health promotion movement has the possibility of re-inventing itself in the twenty-first century” (Baum 2008, p. 464). Part of the problem is identified by Frohlich et al. (2001) who observe, in most traditional health research ‘behaviours are studied independently of the social context, in isolation from other individuals, and as practices devoid of social meaning.’ In attempting to respond to or at least think about this challenge, my aim is to consider how health behaviours at the individual and household level can be understood and possibly intervened in by drawing on theories of social practice as developed by Elizabeth Shove, Theodore Schatzki and Andreas Reckwitz among others. In order to try and link health to consumption I am going to draw on examples relating to food.
- The paper is guided by some overarching questions: What new ways of thinking about and understanding health might assist health promotion in achieving ‘health for all’? How can we better address the socio-technical dimensions of how health is lived and experienced everyday? And in responding to Baum, what might new (socio-technical) directions for health promotion look like?
- As an alternative to focusing on either structure or agency and behaviour, theories of social practice have gained ground in sustainability and consumption research to understand the complexity of daily routines and the implications for sustainability, which has faced similar challenges to health promotion in moving beyond individuals. In particular, social practice theories incorporate the role of technologies and things in daily life, focusing on socio-technical relations rather than those that are social or behavioural in nature only.
- There are various definitions of practices - However, Shove et al have distilled and simplified various definitions in the literature to describe practices as being comprised of three interlocking elements: materials, meanings and skills. For example the practice of eating breakfast is described as….. Meanings of what to eat for breakfast, when, with whom, where, why Skills relating to how to source/shop for/store, prepare/cook and eat breakfast foods and drinks, cleaning up, treatment of waste. And the particular materials and infrastructures involved – the food, beverages, condiments, shops, recipes, kitchens, appliances, cooking utensils, crockery, tables, seating, etc. It is all of these elements together that make up eating breakfast – if one or other is missing, then the practice is unable to be carried out or performed. Each practice – whether it be eating breakfast, running or showering - must be performed habitually by multiple practitioners. If it is only performed by one individual then it is not a practice.
- I want to make two important points regarding the value of using recent formulations of social practice theories in studying health and wellbeing. The latest applications of social practice theory take a post-humanist stance, recognising the role of technologies, materials and things in the construction of everyday life (Reckwitz, 2002a; Shove et al., 2007; Shove et al., 2012; Strengers and Maller, 2012). Normally considered as external factors or ‘context’, social practice theories elevate materials, objects and infrastructures to the status of active elements that co-constitute practices. This is a logical step in an increasingly technologically-dependent social world where a myriad of devices, computers, and machines can have powerful effects on health and wellbeing and ignoring how things and technologies are appropriated, used and co-constitute our everyday existence and their implications for health is a questionable and risky position to maintain. In health, the value of acknowledging a material dimension to human action is that aside from heart rate monitors and other obvious health technologies, the materiality of the built environment could also be theorised in the context of understanding the role of infrastructures in health, such as roads, buildings, parks, bike paths and how they recruit, encourage or discourage people to perform practices with positive health outcomes such as walking to work, using public transport, exercising the body, etc. – Mention IBG paper
- Secondly, social practices are recognised as discrete entities with pasts, present and futures. Descriptions of the practice entity are distinguished from moments of their enactment and performance by individual people or ‘carriers’. In studying complex issues like health, a focus on doing lends itself to the exploration of historical accounts or trajectories of practices over time and space, as well as the potential for future change. In moving away from individuals as the unit of analysis in empirical work, the risk of assigning blame and responsibility for health outcomes to agents whilst ignoring structural effects can be avoided. Individual behaviours are moments in the performances of practices – and are the tip of the iceberg (Spurling et al 2013)…. So thinking back to the practice of eating breakfast, when it is performed, we can only observe the actions involved in the moment of performance – we wouldn’t see the meanings, the shopping and food preparation that would have gone into it, nor necessarily take notice of the tables, kitchen etc where it takes place if using a behavioural approach.
- To try and illustrate how these ideas can be applied in health research I want to briefly talk about some research I am doing on a master planned housing estate designed to improve health and wellbeing. SR is 1200-1500 lot development in Melbourne’s south east growth corridor and is a demonstration project being built by a land developer with a number of other organisational partners including, the local council, state government planning and health organisations, and a national planning body, who together have conceptualising and planning the project together over the last 5-6 years. Aim: “To what extent do best practice planning principles for space and place impact on the health and wellbeing of the community of Selandra Rise?” Key features to address these objectives include (among others): community gardens and a focus on food sustainability early delivery of a community centre with a CD officer – open from Day 1 emphasis on walkability and multi-use parks, and outdoor gym and a range of programs to foster healthy eating and physical activity. The design is structured around three village precincts and once completed will have onsite schools, a kindergarten, and a local town centre with shops and office space for local businesses. At the end of the period of research reported in this paper approximately 550 homes had been completed and occupied and the community centre (‘Selandra Community Place’), a secondary school and one park (Hilltop Park) had opened.
- 55kms from the city Combination of qualitative and quantitative methods Data collection before and after residents move to Selandra Rise to allow for measuring and understanding change over time In-depth interviews in residents’ homes focus on daily routines, neighbourhood experiences and expectations (repeated before and after) Annual survey aims to: Measure the impact of key design features on residents’ health and wellbeing, focusing on the priority health areas Document change over time as the community develops Benchmark and monitor residents’ health and wellbeing
- Residents are mainly young couples (under 40 years of age) buying their first home. Education levels varied and nearly all work full-time in a range of employment sectors. They are culturally diverse with just over half reporting being born in Australia and the remainder being born overseas. 57% of CURRENT residents are overweight or obese Women show a higher rate of overweight and obesity (53%) compared to those in Casey (42%) 2 and the national average (2007/2008) (47%)5 However, men are more likely to be overweight/obese than women (63% to 53%) YOUNG! According to self-reported measures of height and weight, 68% of men and 55% of women were overweight or obese. These figures are higher than Australian national obesity levels (64% of men and 48% of women) for similar self-reported measures from 2007/2008 (ABS 2014). EXTRAS Note: this data focuses on SR residents only - slide excludes representation of ‘underweight’, ie %s do not add to 100 58% getting enough exercise 28% getting sufficient 13% doing no exercise Sufficient is 150 mins or more moderate exercise per week (or 75mins vigorous), insufficient less than this.
- The journey to work is generally long for most participants. 1/3 of residents spending up to 3-4 hours in their cars each day and another third spend from 30-59 minutes one way. As you can see from this map, few worked close to the estate and 25% work in the city EXTRA Mapping of work postcodes Again, spread out – mostly over the south east, east with 1 x Preston, 1 x Essendon (partially off map) 2 in Warragul n = 189
- Nearly 1/5 (18.8%) of residents eat take away food 3 to 10 - or more - times per week. From this we support time might be a factor and access to healthy option another. Very easy to blame households for making bad choices, or to assume that they are uneducated. But using SPTs we find that practices of commuting and working – a practice bundle – are likely to compete with practices resulting in healthier food consumption. Further, because certain materials and infrastructures are not provided – namely local shops and access via public transport – residents maintain their driving practices out of necessity. There also sustainability implications with residents spending a lot of time in their cars. EXTRA Australians on average eat take away 2.5 times per week – Ipsos research. This plays out in the data where….
- On moving to Selandra Rise residents are finding it more difficult to get to and from shops to buy food with about a 12% difference in residents saying it is easy to get to shops in their before neighbourhoods compared to SR. Lucy ‘if we don’t have milk we have to drive…we just thought [the estate] would be really self-sustained and we’d be able to sort of get everywhere without driving’ Explain not paired data – line not causal – indicative of the change.
- When looking at car ownership, we find that households often get a second car when they move to SR, with 2 car households jumping from 61% in their before neighbourhood to nearly 80% in Selandra rise. Only 2 households have no car 4 and 5 car households were future residents still living with their parents. N= 283
- When we asked about satisfaction with their access to public transport, fresh food shops and cafes and restaurants we found that residents at SR were significantly less satisifed. EXTRAChi sq test, significant to 3 decimal places
- Returning to the theory, what this example from Selandra Rise example has shown is that the lack of materials and infrastructure supporting local shops and jobs means that a lot of time is required to perform the practice of working due to long commutes which compete for and absorb time that could be used for other practices the designers of SR are trying to encourage such as exercising, or growing food and veggies or walking to the local shops to buy food. Admittedly some of these probs are due to the delay in the construction of shops. And their resolution is beyond the scope/reach of the partners. Practices do not exist in isolation: they are ‘materially interwoven’ with some practices… And are in competition with others. Empirically this implies that studying one practice in isolation from others with which it intersects or competes with is likely to be limited in its power to explain a current issue or social problem, as well as providing a limited basis on which to design for intervention and change. This word cloud of open responses from the survey shows that residents biggest concerns are access to shops and public transport.
- So what does all this mean for research on health? Applying the latest thinking in social practice theory to health research means that health and wellbeing are considered outcomes of participating in a set of social practices, mutually constructed by the materiality of everyday life, and not the result of individual behaviours or external factors or context.
- Although it is tempting to label or translate healthy and unhealthy behaviours as healthy and unhealthy social practices …it is not easy to do because some behaviours such as smoking or drinking would not necessarily qualify as practices in their own right because they are a small observable part of a wider practice such as going out with friends, seeing a band or often other types of socialising.
- Further, classifying practices as unhealthy or healthy would potentially exclude some practices that have quite significant health outcomes such as driving to work everyday – which also has implications for sustainability and consumption. It also perpetuates existing binaries of good and bad which are often overly simplistic and cut out a lot of the complexity and diversity experienced in everyday life. Instead, ideas of healthy and unhealthy could instead be conceptualised as meanings within a practice. Also, some practices labelled risky or potentially unhealthy may be simply unavoidable, such as such as working at a desk. In essence, every practice could be said to have both good and bad health outcomes and it is the sum total of participation in a particular set of practices that will result in the observed health outcomes of individual people or groups.
- Taking these ideas forward there is a potential opportunity to reframe some existing HP programs and policy to target social practices, instead of behaviours or lifestyles. This would involve thinking about elements (materials, meanings and skills) and how to provide new combinations of elements or replacing elements in existing practices as well as encouraging the spread of new practices. Recognising relationships between practices, bundles and complexes through mechanisms of competition, cooperation and symbiosis among other processes (Shove & Pantzar 2005) For example, to encourage eating a healthy breakfast, interventions could target the meanings of breakfast (what to eat, when to eat), the materials involved (food, places to eat, recipes) and competences (how to prepare, cook, eat breakfast). What is important is that all three elements are the focus of attempts to intervene, as well as looking at what other practices eating breakfast is linked to (for example, shopping for food, cooking and caring for family) and what other practices may be competing for performers’ time (for example, going to work or school). These intersecting practices (which together form a bundle) are also likely to need intervention and it is here that health will most clearly intersect with sustainability and consumption problems.
- Looking to some existing HP programs there are those which emanate a social practices approach E.g. Stephanie Alexander kitchen garden program: practices of growing, harvesting, preparing, and sharing fresh food to change children’s diets – all carried out at school as part of the curriculum. Engaging children in this suite of interconnected and mutually supportive or symbiotic practices has resulted in positive health outcomes as well as positive outcomes or co-benefits for consumption and sustainability from children growing, cooking and eating fresh local food they’ve grown themselves.
- To conclude, I’ve suggested in this paper that social practice theory could be used to reinvigorate or reinvent HP as Baum has encouraged. Theories of social practice could mesh well with HP, because health promotion already: Acknowledges both structure and agency looks beyond ‘health’ policy to all policy sectors connects with ideas of ‘working upstream’ instead of downstream at the illness end.
- Social practice theory could help HP : Collapse or move away from the structure/agency binary – to also move beyond individual focus Incorporate the role of materiality/technology in daily life Account further for the complexity of everyday life, considers other aspects of daily routines beyond ‘healthy/unhealthy behaviours’ Perhaps get closer to achieving the aims of the Ottawa Charter. Finally, using social practices in health research could also be a useful means of connecting health with sustainability and consumption agendas. Thank you. NOTE: the co-constitutive relationship between structure and agency, the centering of bodies and performance over rational thought, and the grounding of their theories of social practice in everyday life.